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President's blog

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President’s blog

 The expectations ‘bar,’ and how it affects welfare and well-being

May-June 2018

It often feels that there is so much happening around us that it can be difficult to distinguish up from down, left from right, true from false. Some examples: Bill Cosby, during my youth thought to be one of the world’s funniest men turns out to be more of a predator. The latest Speights ad, although still blokey, portrays quite a different man to the high country shepherd that we have become accustomed too. Also, from the Herald more people in Auckland than ever before and yet more loneliness, isolation and mental illness. Trump (sorry, had to slip him in somewhere) managed to convince the Brits and French to bomb Syria – I struggled to believe it at first – but then to show his affection for Macron, Trump publicly brushes some dandruff off his (Macron’s) suit; yep, must be fake news.
It seems like the world has turned upside down. I get this sense of paradox when I listen to conversations within my own department and when I visit other departments as NZSA President (which although I find a bit nerve wracking I also value and enjoy). While departments are bigger than ever before and work conditions arguably better than ever before there is an underlying sense of frustration, stress, task overload and disempowerment. The reasons? Clearly multifactorial: social media, values, management, standards etc.

I wonder if this is secondary to a general increase in expectations. Greater expectations of what we can do as clinicians from patients, colleagues and ourselves. Greater expectations of what we should be achieving as individuals in our working lives, family roles and leisure time. In moderation this is a good thing as we should be ambitious. However, if the bar is set even slightly too high we will never reach it. Bottom line; the bar has always been too high in medicine with a resultant culture of perfectionism and blame. None of us can reach this standard all the time hence the high rates of burnout, depression, anxiety, shame and suicide. (1) We are planning to address some of these issues at this year’s “Behind the Scenes” NZSA Annual Forum (4 August) which this year follows the Christchurch meeting (3 August) “Shakes.” We are very fortunate to have a range of speakers, including from the HDC, police force and the Welfare Special Interest Group.
So, going back to the expectation bar; I hypothesise that in healthcare it has never been higher but unfortunately is just slightly higher than the delivery bar. For us at the coalface this manifests itself as a relentless pressure to increase complication free output with reduced resource. Clearly impossible and yet a daily expectation that we routinely try to achieve. The rubber hit the road for me recently at a department meeting. Being good-natured and conscientious types, we discussed how to facilitate increased productivity despite being short on FTE and one of the options discussed was to sacrifice non-clinical time. This got me thinking about value proposition and non-clinical time specifically. As President of your society I spend a lot of time thinking about value proposition and how to measure it. How does one quantitate the value of say quality analgesia, of preoperative assessment, of non-clinical time, patient centred care, anaesthetic technicians, throat packs, the NZSA? I refer you back to reference (1) and to a recent ASMS publication on patient centred care. (2) The outcomes are relatively soft and difficult to measure, yet arguably more important in the long run than many of the current KPIs.

  1. Firstly preoperative assessment and a bit of light satirical relief from my philosophising above. A colleague here at Waikato recently sent a paper entitled Complete relinquishing of anaesthetic conscientiousness, optimisation and nuance (CRAC-ON) trial. (3). It looked at the benefit of preoperative assessment clinics. Here is a small excerpt:

“In the world’s first quadruple blinded study, blinding occurred at four levels:

  1. Investigator – all investigators were blinded as to which group patients had been assigned.
  2. Patient – patients were blinded as to whether they had undergone pre-operative assessment by sending them to a mock preoperative consultation conducted by television actor Claudia Karvan. To avoid the perception that patients allocated to this group were having their time wasted, the mock preoperative consultation was made both entertaining and informative by the inclusion of a video about global warming and a brief performance by a circus clown.
  3. Literal – anaesthetists assigned to administer anaesthesia to patients in the non-assessment group were blindfolded to prevent them knowing the patient’s age, weight or inadvertently making any sort of pre-operative assessment.
  4. Ethical – the hospital’s ethics committee was blinded to the fact that this trial was being undertaken.

They conclude, as in most things in life, that there is probably a happy medium.

Similarly, we often realise the value of a commodity only after it is no longer available, compared to when it was present and done well. With Anaesthetic Assistants for example, one certainly notices when the standard is lacking as opposed to the converse. The Medical Sciences Council (the regulatory body for Anaesthetic Technicians) has undertaken a review of their scope of practice.  This was opportune as several aspects of both training and practice have been up for discussion over recent years. It is however a bit unsettling for the ATs, as their future is possibly unclear and in some areas potentially under threat. We have been asking, as the NZSA executive, how we can best support our anaesthesia team mates at this time. I have chatted with Andrew Warmington, a member of the Medical Sciences Council. His answer was that perhaps the major threat to technicians at the moment is ironically, a workforce shortage.  So, for us as anaesthesiologists, we should support and encourage AT training however we can.  At this point, the finer details of both the degree process being look at by AUT and the eventual outcome of the MSC scope of practice review are unknown. We are watching this space closely.

The ASMS publication on Patient Centred Care which I mentioned earlier, I confess to initially having been quite cynical about and thinking that all health interactions are patient centred. However, after reading the ASMS blurb (4) I realised that this is a high level concept and philosophy that we have been fostering in anaesthesiology for some years. It is about having the time to increase our value proposition; time for MDT meetings, time for developing our cultural competence, time for conversations with other colleagues, time to write blogs.

Finally, just to contrast the above with a clinical value, that of throat packs. A recent publication (5) questions the value of anaesthetically placed throat packs.

As always, may the force be with you and feel free to contact me about issues I have raised in my blog.

David

  1. J Robertson and B Long, Jounrnal of Emergency Medicine 2017. https://doi.org/10.1016/j.jemermed.2017.12.001
  2. Patient Centred Care
  3. https://www.google.com/search?client=safari&channel=mac_bm&source=hp&ei=nfTkWuLeJ8iy8QXrsKyQCw&q=anaesthesia+2016%2C+71%2C+1408&oq=anaesthesia+2016%2C+71%2C+1408&gs_l=psy-ab.3…4584.24403.0.25130.26.23.0.2.2.0.542.5108.2-13j1j2j1.17.0….0…1c.1.64.psy-ab..7.12.3167…0j0i22i30k1.0.v1d6pZKRjXM
  4. Health dialogue: Issue 15 March 2018.
  5. Anaesthesia 2018, 73, 612–618